For most economists working in the field of health care,particularly those working on the economic evaluation ofhealth technologies, the logic of being concerned about therelative effectiveness of competing interventions and theopportunity cost of the resources involved is instinctive.Difficult choices have to be made within the inevitablylimited resources available to publicly funded (and indeedprivate insurance-based) health care provision. It is an easystep then to suggest one should maximise the utility of apopulation within the constraints of a predetermined bud-get or at politically acceptable future cost. For manyeconomists, though not all, it requires only two small stepsto move from utility maximisation, to health maximisationand then to operationalise that as QALY maximisation.And, some key reimbursement and/or coverage authoritieshave bought into that argument as a logical, operationaldefinition of their mandate.Economists, of course, readily concern themselves as towhether the underlying concepts of cost-effectivenessgenerally, and of QALY maximisation with a budgetconstraint in particular, are consistent with economists owndefinitions of logical behaviour as expressed in welfaretheory (for example, the paper by Bengt Liljas and thesubsequent comments in this Journal) [1–3]. Those whotake an extra-welfarist view of the issues may be lessconcerned about the fit with economic theory and moreabout the fit with decision-makers explicit or implicit cri-teria [4].What is more, there is a widespread assumption thatexplicitness and transparency are desirable characteristicsin the process of making the necessary difficult choicesabout what can, and should, be afforded (as, for example,in a proposed framework for classifying decision-makingsystems using technology assessment) [5]. But it is notclear that such explicitness is desired by all. Many politi-cians, and perhaps the public they represent, often seem towant to avoid clarity and transparency and prefer difficultchoices to be fudged.In the UK, where ‘rationing’ has been widely acceptedas a necessary characteristic of the NHS, the NationalInstitute for Clinical Excellence (NICE) was originally soldto the public as a way of avoiding the use of ineffectiveinterventions and ensuring that ‘effective new treatmentswill be spread promptly and evenly around the country’[6]. Nevertheless, NICE has led the way in making itsdecisions on the availability of specific technologies astransparent and explicit as possible and not hiding the factwhen it does not recommend an effective medicine becauseit is not also acceptably cost-effective. But this ‘virtue’ oftransparency and explicitness receives a very mixed reac-tion in the media. Some commentators have noted recentlythat ‘public understanding and support for the work ofNICE as evidenced by the UK’s media coverage, with veryfew exceptions, has been increasing’. [7] But virtually,every NICE decision that does not recommend the use of anew drug, or limits its recommended use to a subset of thepatients within its broader licence, is still strongly criticisedin (politically important) parts of the popular daily press.Arguably, one of the political drivers for the proposedmove to value-based pricing (VBP) is to avoid the politi-cally difficult headlines when NICE ‘says no’. Instead, if